Citation

Abstract

This qualitative case-study discusses the experiences of one individual with a
neurodegenerative disease which is largely undiagnosed. This study provides the reader
with a history of the subject’s mental health diagnoses as well as their symptomology and
the progression of the illness. There is a specific focus on the patient’s history of Bipolar
I and prior diagnosis of a meningioma. A detailed discussion of the patient’s presenting
problems is also discussed in this study.

Introduction

The researchers in this brief case-study sought to present a complicated case of a
largely undiagnosed neurodegenerative disease in an effort to educate others about various
symptomologies and how it effects the patient as well as the family.

Background information

Prior to the onset of current symptomology, the subject had a significant mental health
history. This history complicates current functioning and diagnoses as well as provides
problematic pharmaceutical measure to alleviate symptoms.

Beginning psychotherapy

The subject reported experiencing increased anxiety due to elevated levels of
depression of unknown causality. At this time the subject received his first referral to see
a psychologist at the age of 30. The subject received person-centered psychotherapy at 50
min intervals once per week for a period of one year. Subject stopped receiving therapy
on his own accord. The psychotherapist recommended bibliotherapy as a measure of
continuity of care and offered to see him should he choose to reestablish the therapeutic
relationship. During this initial time in therapy, the subject received his first diagnosis of
Bipolar I.

Bipolar I diagnosis

Specific symptoms included increased levels of energy where he reported staying
awake for 2-3 days successively. The subject reported feelings of euphoria and delusions
in which he had beliefs that he and the world were wonderful and believing he was the
Messiah. This was also accompanied by pressured speech. Beliefs that he could fix anyone
and any problem. He believed that he could solve anything which led to risky behavior such
as becoming a confidential informant for the police.

The subject also reported having vivid dreams so much that the symbols within them
became a perseveration for learning and growth. He also believes that he had some issues
pertaining to PTSD from childhood sexual abuse and his service in Vietnam. However, this
went undiagnosed. He reported dreams of his abuser’s house burning down. Interestingly,
his abuser’s home was indeed destroyed in a fire, thus alluding to more magical and
Messiah-like delusions. Soon after his diagnosis, the subject began taking Lithium. The use
of this medication was successful in that he believed his moods “evened out” and he did not
experience the peaks of the mania or the lows of depression. Subject reported that he was
relatively stable for the next 20 years.

The subject was advised to cease his regimen of Lithium due to issues surrounding
kidney function due to new research. At this time he was taken off of Lithium and placed
on a few different medications such as combinations of SSRI’s, mood stabilizers, and
anticonvulsants in an attempt to find a psychopharmaceutic cocktail that would help
alleviate symptomology. Following his Lithium elimination, the subject developed constant
suicidal ideation. The subject was placed in a outpatient managed care facility where he
returned for treatment daily for a period of three weeks. At this time, treatment consisted
of education, group therapy, art therapy, and individual therapy.

After his initial partial hospitalization, the subject was placed in a group therapy
setting one time a week for 8-9 months for monitoring purposes. Therapy ceased when his insurance changed, and treatment became cost prohibitive. However, the subject was still on medication under the care of a psychiatrist.

It is important to note that the subject was diagnosed with a
brain tumor in 2010 after the subject was showing some stroke-like
symptoms, visual disturbances, and balance issues. As a result, his
doctor conducted a head CT and concluded that his tumor was a
meningioma that was calcified, small, and benign. He reported having
two subsequent CTs in 2012 and 2014 for monitoring purposes, and
the meningioma has not grown or changed. In addition, he had a MRI
at the beginning of 2017, which also resulted in confirming that his
meningioma has still not grown or changed.

Current difficulties

Fifteen years later, the subject gradually began to notice changes
in his gait and mentation. At this time, the subject was in his early
60’s. He experienced noticeable decline in his short-term memory
processes while his long-term memory processes was intact. For
instance, he walked into a restaurant and saw a vintage baseball game
on TV. He recalled the date the game was played, the score, and the
principal players, however, he could not remember what he had for
lunch. He also remembers feeling uncomfortable with the situation.

The subject recalls experiencing delusions as a life history that
was not his own, which in his words he describes as “not fantasy and
not dissociative” he equated this as a feeling of intoxication. The
subject was placed on the anti-psychotic, Seroquel, and subsequently
developed tardive dyskinesia.

Parkinson’s diagnosis

He was diagnosed with Parkinson’s disease, and the subject
was prescribed the dopaminergic, Carbidopa-Levodopa, which was
discontinued after two weeks due to the ill side effects and the lack
of efficacy. The subject developed depression after his Parkinson’s
diagnosis as he grappled with losing some function. He was then
urged to apply for disability benefits, and he lost his job as a result
of the diagnosis.

Other symptomologies

Currently, the subject still has Parkinsonian symptomologies.
However, his current neurologist and psychiatrist do not believe that
Parkinson’s disease is the correct diagnosis. They believe that his
difficulties stem from something else entirely, or that he has something
else in addition to his Parkinsonian symptomology. He still carries
a Parkinson’s diagnosis, but his neurologist added the diagnosis
of Cognitive Communication Deficit as his primary diagnosis. He
actively has difficulty sleeping with markedly noticeable increase
in REM sleep behavior disorder. The subject often cannot decipher
his dreams from reality, and it requires a degree of mental effort to
differentiate between the two. The subject reported a necessity in
asking people if a particular conversation or event occurred because
he is no longer able to decipher dreams from reality.

The subject also reports repetitive visual hallucinations. He
reported seeing rapid movement on the periphery, so quick that he
cannot ascertain a definitive shape or form. He reports seeing cats
that are not there. He mistakes certain objects for others. Seeing
visions such as seeing a pigeon walking across the grocery store floor,
bald eagles flying overhead, seeing his wife driving without looking at
the road, but resting her head on the steering wheel.

Decline of cognitive abilities

He reports having noticeable decline his cognitive abilities by
saying “I do not think anymore. I sit by myself and cannot form
thoughts; I just cannot focus on anything, it’s like slamming against
a wall”. He has difficulty with his short-term memory function, often
forgets to eat or what he is doing in the middle of a task, such as
when he goes into a room, he cannot remember why he went there.
The subject does, however, report maintaining adequate long-term
memory and is able to recall facts and events from decades ago. He
has reported that he often cannot remember how to work the oven
and it takes a period of time for him to think about, and remember
how to use it. The subject is also no longer able to drive due to his lack of orientation. He also indicated that he is not entirely sure he
can think abstractly anymore.

The subject either is unable to attend to or is unaware of
any autonomic dysfunction. He does, however, report feelings of
excessive sleepiness during the day. He naps throughout the day and
often falls asleep while seated. The subject has diminished spatial
awareness, frequently has problems in ascertaining where he is in
relation to the world around him. He has difficulty with directions
as well. He remembers driving up a freeway off-ramp for example.
He also became so disoriented that he went the wrong direction on
the freeway for several miles, ending up hours away from his original
destination.

Ambulation

Physically, the subject has diminished muscle tone and an
increasingly loss of balance. His gait is more slumped over than
before. He needs the assistance of a cane or walker to aid him in his
ambulation. He also requires a person close by as he bathes in case
he falls, and uses a shower chair. He also reports constant back pain
above his pelvis and extends to his midline. He now sleeps sitting up
in a rocking chair as it is more comfortable.

Tremors

The subject began experiencing Parkinsonian-like tremors in the
left hand at rest which gradually increased in frequency and then
began in the right hand as well. He recently began experiencing
tremors with purposeful movements which results in more vigorous
tremors. More recently, he is experiencing tremors in his legs.

Activities of Daily Living (ADL’s)

Currently, the subject has difficulty in eating as he needs to be
reminded to eat and his ability to cook food is diminished due to
weakened mentation. He can bathe unassisted but needs someone
in close proximity as a protective measure. He can wash his clothes
independently but needs reminders to change them as he can wear the
same clothing for several days without becoming bothered by it. The
subject needs assistance in staying focused as he is easily distracted
when performing multi-step tasks. He experiences difficulty in
writing as his tremors have adversely affected his penmanship, while
the cognitive difficulties have greatly impacted his focus of thought.
Communication has become laborious for the subject as he has
increased difficulty with anomic and expressive aphasia.

Diagnosis

Client was referred to a neurologist who took a history
regarding the onset and current presenting symptomology. A
detailed discussion about the clients hallucinatory experiences
were analyzed. The neurologist noted that his symptoms lacked
those found in Parkinson’s disease, but acknowledged Parkinsonism
attributes. The client presented with cognitive decline which was
evident over a longitudinal period of one year. The client was then
diagnosed with Lewy Body Dementia.

Treatment

In terms of treatment, the client was prescribed the
cholinesterase inhibitor, Exelon in addition to his regimen of 1250
mg of Valproic Acid, 300 mg of Lamotrigine, and 60 mg of Fluoxetine
daily [1]. He was referred to physical therapy to ascertain if the use
of assistive devices would be beneficial. He was also referred to a
Speech, Language, and Learning Center which will assist in helping
the patient develop coping skills during his gradual loss of cognitive
and physical faculties [2]. Currently, there is no known cure for Lewy
Body Dementia [3].

Conclusion

In conclusion, this case study highlights one individual’s journey
of the arduous path from the onset of symptomology to formal
diagnosis, which lasted two years. It is imperative to diagnose early
for the best course of treatment [4]. During this time, the client and
his family underwent a period of frustration and sadness as tests were performed and no final diagnosis were made. The client and his
family felt a sense of closure [5]. However, the client identifies as an
individual still in the throngs of the grieving process [6].

References

Wong CW. Pharmacotherapy for dementia: A practical approach
to the use of cholinesterase inhibitors and memantine. Drugs &
Aging. 2016 Jul;33(7):451-460.(Ref.)